Behavioral treatment of hyperlipidemia: techniques, results, and future directions

Poor adherence is a contributor to viral breakthrough in patients with chronic hepatitis B

Objective

The objective of this study was to explore the risk factors of poor adherence of nucleoside analogs (NUC) treatment in chronic hepatitis B (CHB) patients and the virological changes in patients with poor adherence.

Subjects and methods

A total of 205 CHB patients were enrolled. The patients’ demographic data and family history were collected. NUC adherence was calculated every 12 weeks as follows: number of NUC tablets taken by the patients was divided by the number of NUC tablets prescribed. NUC adherence > 90% was defined as good adherence of NUC treatment.

Results

NUC adherence of male patients was significantly lower than that of female patients. Adherence among patients with previous NUC treatment was poorer than that of patients without previous NUC treatment. Multivariate analysis indicated that female gender (OR =0.367, P=0.013) was the protective factor for NUC adherence in CHB patients, while pretreatment with NUC was the risk factor for NUC adherence (OR =3.209, P=0.002). A total of six patients in the good adherence group experienced virological breakthroughs while 15 of 77 patients in the poor adherence group experienced virological breakthroughs (P=0.001). Similar trends were observed in NUC resistance. Four of the 128 patients with good adherence developed NUC resistance while nine of the 77 patients with poor adherence developed resistance (P=0.015). Multivariate analysis suggested that pretreatment with NUC (OR =3.133, P=0.031), NUC drugs (OR = 3.951, P=0.010), and adherence (OR =2.749, P=0.046) were independent risk factors associated with virological breakthroughs and that NUC drugs (OR =7.083, P=0.005) and poor adherence (OR =4.951, P=0.009) were independent risk factors for NUC resistance.

Conclusion

Male gender and pretreatment with NUC were risk factors associated with NUC adherence. Poor NUC adherence is more likely to induce virological breakthroughs and NUC resistance. For patients with poor NUC adherence, it is necessary to give timely education to improve treatment adherence.

Lifestyle and psychosocial risk factors predict non-adherence to medication

Blood pressure and cholesterol reduction have proven effective to reduce cardiovascular disease (CVD) risk, yet adherence to medical therapy is suboptimal and contributing factors to non-adherence are not well-established. The purpose of this study was to determine the prevalence and predictors of non-adherence to blood pressure and cholesterol-lowering medications in individuals who participated in an NHLBI-sponsored evaluation of a hospital-based screening and outreach program for high-risk employees and the community. This was a cross-sectional study of 371 adults (mean age 60 years, 57% female, 60% non-white) who were eligible to participate if they were men >40 years, women >50 years, or had established CVD or CVD-risk equivalent. Each participant received a comprehensive standardized CVD screening evaluation; medication non-adherence was defined as missing any pills for high blood pressure or abnormal cholesterol in the past week. Associations between participant demographics, lifestyle and psychosocial risk factors, and non-adherence were assessed using logistic regression to adjust for confounders. The prevalence of taking medication for high blood pressure or abnormal cholesterol in the study population was 48% and 38%, respectively. Among those participants, 14% reported missing high blood pressure pills and 23% reported missing cholesterol pills in the past week. Significant (p<0.05) univariate predictors of non-adherence to blood pressure medication were smoking, depression, feeling sad or blue for 2 weeks or more, and eating fast food ≥2 times per week. In a multivariable regression model adjusted for confounders, participants who reported missing any blood pressure pills in the past week were 6.6 times more likely to have uncontrolled hypertension (≥140/90 mmHg) compared to those who were adherent (95% CI = 2.1-20.2). Age <65 years and eating outside the home ≥2 times per week were significantly associated with non-adherence to cholesterol medication even after adjusting for measured confounders. Non-adherence to preventive medications was associated with poor blood pressure control and several lifestyle and psychosocial risk factors for CVD. This information may be clinically useful to help identify individuals who may be non-adherent to medical therapy and at increased CVD risk.

Patient self-management support: novel strategies in hypertension and heart disease

Cardiovascular diseases (CVDs) have become the leading cause of death and disability in most countries in the world. This article addresses how patient self-management is a crucial component of effective high-quality health care for hypertension and CVD. The patient must be a collaborator in this process, and methods of improving patients' ability and confidence for self-management are needed. Successful self-management programs have often supplemented the traditional patient-physician encounter by using nonphysician providers, remote patient encounters (telephone or Internet), group settings, and peer support for promoting self-management. Several factors need to be considered in self-management. Given the health care system's inability to achieve several quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to which these interventions and programs can be integrated into primary care, their effectiveness in different groups, and their sustainability for improving chronic disease care.

Study protocol: Couples Partnering for Lipid Enhancing Strategies (CouPLES) - a randomized, controlled trial

Background

Almost 50% of Americans have elevated low-density lipoprotein cholesterol (LDL-C). The behaviors required to lower LDL-C levels may be difficult to adhere to if they are inconsistent with spouses' health practices, and, alternatively, may be enhanced by enlisting support from the spouse. This trial extends previous trials by requiring spouse enrollment, teaching spouses how to provide emotional and instrumental support, allowing patients to decide which component of the intervention they would like to receive, and having patients determine their own goals and action plans.

Methods

Veteran outpatients with above-goal LDL-C (N = 250) and their spouses are randomized, as a couple, to receive printed education materials only or the materials plus an 11-month, nurse-delivered, telephone-based intervention. The intervention contains four modules: medication adherence, diet, exercise, and patient-physician communication. Patients decide which modules they complete and in which order; modules may be repeated or omitted. Telephone calls are to patients and spouses separately and occur monthly. During each patient telephone call, patients' progress is reviewed, and patients create goals and action plans for the upcoming month. During spouse telephone calls, which occur within one week of patient calls, spouses are informed of patients' goals and action plans and devise strategies to increase emotional and instrumental support.

The primary outcome is patients' LDL-C, measured at baseline, 6 months, and 11 months. Linear mixed models will be used to test the primary hypothesis that an 11-month, telephone-based patient-spouse intervention will result in a greater reduction in LDL-C as compared to printed education materials. Various process measures, including social support, self-efficacy, medication adherence, dietary behavior, and exercise, are also assessed to explain any change, or lack thereof, in LDL-C.

Discussion

Given the social context in which self-management occurs, interventions that teach spouses to provide instrumental and emotional support may help patients initiate and adhere to behaviors that lower their LDL-C levels. Moreover, allowing patients to retain autonomy by deciding which behaviors they would like to change and how may improve adherence and clinical outcomes.

Trial Registration

The ClinicalTrials.gov registration number is NCT00321789.

Community nutrition education for people with coronary heart disease--who attends?

A qualitative food-frequency questionnaire was administered by mail to a representative sample of 137 people previously diagnosed with possible or definite myocardial infarct. Seventy-eight percent of subjects returned a completed questionnaire and were subsequently invited to attend local tastings of foods with the National Heart Foundation Tick of Approval. These tastings were organised and promoted with the active involvement of the local branch of the Australian Cardiac Association. The purpose of this study was to measure voluntary participation by people with coronary heart disease in community nutrition education and to identify any self-selection bias with respect to eating habits among the participants. A dietary risk score, which was the proportion of all food choices that were high in fat, was calculated from the data. Eighteen per cent of subjects who answered also participated in the food tastings; there was a statistically significant association between membership of the Australian Cardiac Association and being a participant. Participants had a significantly lower risk score (P < 0.01) after adjustment for age, sex and membership of the association. The results suggest that voluntary participation by people with heart disease in community nutrition education is low and that there is a self-selection bias, with those at highest dietary risk being least likely to attend. The use of existing community networks to recruit participants is also discussed.

Personal and mediated health counseling for sustained dietary reduction of hypercholesterolemia

Methods of effective cardiovascular risk reduction that are suitable for use in clinical settings are needed. Several behavioral interventions were designed to be compatible with office-based medical practice, to be delivered by paraprofessional counselors, and to be of low intensity and low cost. Eighty-three hypercholesterolemic volunteers were assigned to one of three experimental conditions (face-to-face counseling, mail and telephone counseling, initial session only). Twenty-six nonrandomized subjects served as a no-contact group and were followed for 1 year. Participants in the first three groups received risk factor education, behavioral recommendations, and a packet of materials, while those in the face-to-face and mail/telephone counseling groups were contacted for five brief follow-up sessions over a 4-month period. At the 1-year follow-up evaluation, subjects in the face-to-face and mail/telephone counseling conditions showed decreases in plasma cholesterol of 6.2 and 4.6%, respectively (P less than 0.01), while the other two groups evidenced small increases. There were no differences by condition for plasma triglycerides, systolic or diastolic blood pressure, or weight. Low-intensity, low-cost behavioral interventions delivered by paraprofessionals can produce long-term decreases in a major cardiovascular risk factor. Physicians are encouraged to incorporate similar interventions into their practices.